Barry Thraves

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Sarah Morris _ = o)
0116 454 5417 | sou " | c xy

0116 2211550 ne T

sarah.morris@leicester.gov.uk 17 EEC 715 r¢ . 1 )

ASC/SF/SM/5102/21161 ge

16 December 2015 a | Leicester
: City Council

Ms L C Brown

Assistant Coroner, Leicester City and South Leicestershire

Town Hall

Town Hall Square
Leicester, LE1 9BG

Dear Ms Brown,
Re: Barry Thraves

Thank you for your report made in accordance with paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.

Following receipt of your letter, the Head of Service for Adult Mental Health has met
with colleagues within Adult Social Care here at Leicester City Council and has
discussed the case and concerns with the Service Manager in Leicestershire
Partnership Trust. | am aware that Leicestershire Partnership Trust will be
responding separately to you and providing their own feedback to the concerns.
Officers within Adult Social Care have considered very carefully the concerns and
what lessons there are to be learnt from this case. Please be assured that we have
taken this matter very seriously and please find below our responses and action
plan in relation to each of your matters of concern.

i) Psychiatric follow up was planned for 2 months but an appointment was
not offered for 4 months; on Barry not attending no action was taken and
there was no evidence before the court that any clinical consideration of
his risks was undertaken at the time.

This concern relates to Leicestershire Partnership Trust's involvement with Mr
Thraves and | am aware that The Trust will be responding to you on this point.

ii) Community support did not take place as planned, and the family were not
even made aware that this was awaited and Barry was on the list. It was
not clear what, if any, information Barry had received apart from a very
brief letter of discharge that specifically did not mention the community
support.

Case records show that ward staff Beaumont Ward at the Bradgate Unit referred Mr
Thraves to Adult Social Care on 11 November 2014 on his discharge from hospital.
This referral was made to Adult Social Care’s Single Point of Contact and a duty
worker within this team contacted Barry and his sister between 11 and 13
November 2014 as part of the process of gathering information about Mr Thraves's
needs. Both Mr Thraves and his sister identified that he needed support to access
AZ

_ 7 LEICESTER CITY COUNCIL
Rutland Wing, 3” Floor City Hall, 115 Charles Street, Leicester, LE1 1FZ
www.leicester.gov.uk

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the community and social inclusion options and so it was explained to him that he
would be transferred to a Mental Health Team for a full assessment. The case was
transferred to the AMH (West) Team on 14 November.

It is most unfortunate that from the date of transfer to a Mental Health Team Mr
Thraves had to wait for an assessment, which subsequently resulted in his sister
contacting his Social Work Team.

In order to ensure an individual, and any relevant persons, are aware of the process
following a referral to Adult Social Care a new process has been developed which
will be effective from 1 January 2016. The process shall be triggered where Adult
Mental Health identifies that someone will need to wait more than 14 days for an
assessment from the point that the case is transferred to the team. Adult Mental
Health Teams will write to them explaining that they have been referred for an
assessment, that they will be seen as soon as possible but that they should contact
the team if anything changes. Any appropriate leaflets about other support services
available will be sent out at this point.

The Team Leaders will be responsible for this process and the fact that this letter
has been sent out will be recorded within the system. This will ensure that
individuals have the contact details for the team who will be dealing with their
assessment and so on and understand the process that will be taken.

Having the details in writing will also make it easier for people to share this
information with family and carers. Where there is an identified carer whom the
person wants involved with their care the team leader will send a copy of that letter
to the carer.

In order to ensure all staff are aware and adopt this process and email was sent to
the relevant teams, by the Head of Service on 15 December and Team Leaders will
discuss this in team meetings so that all workers are aware of the process.

iii) The expectation of the Local Authority is that appointments should take
place within 28 days, but the unit is significantly under-resourced and
delays are common and appear to be tolerated, and have been for some
time. Earlier timely appointments could assist in identifying and
intervening with relapsing patients. This opportunity was lost.

The Local Authority aims to assess people as soon as possible. There is no longer
a national indicator to assess people within 28 days of referral but Adult Social Care
works towards these timescales.

Unfortunately at this time the team was under particular pressure due to long term
sickness and vacancies, subsequently resulting in individuals waiting a long period
of time for assessments. It is most unfortunate that this consequently impacted
upon Mr Thraves and also other people awaiting assessment at that time.
Fortunately, the staffing situation has now improved, vacancies are filled, and
waiting times for assessment have reduced.

At times when Team Leaders are unable to allocate cases to workers immediately,
Team Leaders are responsible for prioritising and reprioritising cases awaiting
allocation.

3

3\..

This is done on a weekly basis, checking the cases requiring allocation and the
caseloads of workers within the team to identify people who can pick up new cases.
When a Team Leader is off work this responsibility is picked up by the covering
manager, and there will always be a covering manager.

In accordance with new processes, from 1 January 2016, anyone awaiting
allocation will be contacted fortnightly by phone to check whether anything has
changed and if the case needs re-prioritising. Team Support Workers within each
team will undertake this task and report back to the Team Leader, who can then
reprioritise cases as required. This process has been implemented via email from
the Head of Service to Team Leaders on 15 December 2015 and will be followed up
by conversations in team meetings.

Adult Social Care is currently restructuring and establishing an Enablement Service
to work alongside the Adult Mental Health Social Work Teams. This service is
designed to be in place for 1 April 2016 and will offer adults with mental health
problems practical support from the point of referral so that no one should have to
wait for an assessment.

iv) Communication between the community mental health team and other
stakeholders was poor, with important information that had been
identified (that Barry was depressed and not compliant with his
medication) not being shared with the GP, nor were the GP or psychiatric
team aware that Barry was not receiving any community support.

It is noted that the AMHP'’s report to the Coroner identifies that the psychiatrists and
AMHP assessing Mr Thraves were aware that he was not compliant with his
medication. It is acknowledged that it should be standard practice for information to
be shared with relevant professionals, such as the GP. In order to ensure this takes
place in practice the Head of Service has e-mailed all AMHPs on 15 December
2015 to remind them of the importance of feeding back to GPs following an
assessment under the Mental Health Act, where the GP was not part of that
assessment. In order to reinforce this practice a specific process to be followed has
been implemented which requires the AMHP to provide information by telephone no
later than the following working day after the assessment, and for such feedback to
be subsequently provided in writing, via letter, outlining any relevant information
within two days.

Social workers across Adult Mental Health have been reminded of the importance
of feeding back to the whole multi-disciplinary team and to carers, not solely the
Registered Medical Officer.

v) Information was not made readily available for either Barry, or the family
who were trying to support him, of who was involved in his care, the
extent of their role and who to contact to discuss this further or in the
case of any deterioration or change in presentation. This made the task of
the supportive sister considerably more onerous and difficult and
introduced unnecessary further delays in obtaining support for Barry at a
time when his mental health was deteriorating and he was in need of
urgent review.

lA

A\..

The process identified at point ii above, specifically the letters that will be sent to
anyone who has to wait for an assessment from an Adult Mental Health Team, will
explain Adult Social Care's role and how to contact the team should the situation
change. As detailed above, having this information in writing will enable individuals
to share this with family and carers.

Officers working within Leicester City Council's Adult Mental Health Services were
saddened to hear of Mr Thraves's death and as a result of his death and the
circumstances surrounding it have considered extremely carefully the support
provided to him. This was done through conversations between the Head of
Service, Locality General Manager, Team Leaders and the AMHP. The processes
identified and implemented, to be effective from 1* January 2016 are processes
which aim to improve that service for people requiring their support.

| do hope that the above answers your concerns and identifies the ways in which
Adult Social Care will be working to take action to prevent future deaths. However,
if you have any queries regarding this please do not hesitate to contact Sarah
Morris, Head of Service for Adult Mental Health on 0116 454 5417.

Yours sincerely

Strategic Director, Adult Social Care

Leicestershire Partnership NHS)

Direct dial: 0116 2950821/07786 111055
Email: frank.|usk@leicspart.nhs.uk

Our ref: BMT/REG28/1215

17 December 2015

By email to Leicester.coroner@leicester.gov.uk
Mrs L Brown

Assistant Coroner

Leicester City and South Leicestershire

The Town Hall

Town Hall Square

Leicester LE1 9BG

Dear Mrs Brown

Re: Barry Max Thraves

NHS Trust

A University Teaching Trust

Corporate Affairs

Room 170, Penn Lloyd building
County Hall

Leicester

LE3 8TB

Tel: 0116 295 1350
Fax: 0116 225 5233

www. leicspart.nhs.uk

Further to your report dated 26 October 2015, in accordance with paragraph 7,
Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, | offer the following response.

We have investigated the matters of concern that have arisen during the course of
the inquest of Mr Barry Thraves. Please be assured that Leicestershire Partnership
NHS Trust (LPT) has taken these matters very seriously and undertaken a review of
the circumstances of the case in response to concerns raised. | trust that you and Mr
Thraves' family will be satisfied that we have taken the appropriate measures to

reduce the risk of a similar incident occurring.

The Serious Incident investigation was conducted in the immediate period after Mr.
Thraves' death. It was signed off by our commissioners in November 2015 and we

met with Mr Thraves' sister on 10 December 2015.

We offer specific detail to the responses to the Coroner's concerns below.

1. Psychiatric follow up was planned for 2 months but an appointment was not
offered for 4 months; on Barry not attending no action was taken and there was
no evidence before the court that any clinical consideration of his risks was

undertaken at this time.

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

We agree with the inquest findings. The LPT Did Not Attend (DNA) Policy (attached
as appendix 1) is clear that it should be a clinical decision about what action should
be taken following a missed outpatient appointment.

This communication with the GP is expected to be recorded by an entry in the
medical notes. No such record was found on the occasion of Barry's last
appointment. There was no letter evident in the clinical records regarding Barry's
non-attendance at his appointment and no letter was sent to the GP which would
have indicated when the next appointment was due. It was written in the clinical
records by the doctor that the next appointment was to be arranged for 2 months’
time.

Actions taken/planned:

All community mental health team staff have been reminded of the requirements of
the DNA policy and their duty to follow it. Regular spot checks will be carried out to
ensure that compliance is maintained. The Trust DNA policy is in the process of
being reviewed and will be available in February 2016 and a clear flow chart of
steps to take in case of a patient not attending their appointment is included in the
new policy. The Service Manager Adult Mental Health Community Services has
circulated an interim version of this flow chart to all Community Mental Health Teams
to reinforce awareness of the procedure following a missed appointment while
awaiting the release of the new policy. The flow chart is attached as appendix 2.

In the period between completion of the investigation and leading up to the
Coroner's inquest LPT has been undertaking a programme of specific work to
ensure that the maximum use of clinical appointment slots are available in the Adult
Mental Health Outpatients department thereby increasing the availability of
appointments to our patients. This will reduce the numbers of people who are not
attending appointments.

Specifically our new patients are now being contacted a week before their scheduled
appointment to remind them of the appointment date and time. If a patient is unable
to attend then the appointment can be offered to someone else. Patients who
missed their last appointment are also telephoned to remind them to attend and
these patients are also bought to the attention of the clinician so that an assessment
can be made as to whether or not any further action is required. A text reminder
facility is available to patients who opt into the service and the publicity for this is
being reviewed to encourage take up.

LPT is also working towards a ‘partial booking’ system for outpatient appointments
whereby appointments are booked much closer to the scheduled date to be seen
allowing for a more flexible use of available appointments and a reduction in
cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to
Clinical Director approval and an action plan to monitor compliance and
improvement is scrutinized for assurance at the LPT Quality Assurance Committee.

Since the beginning of November 2015 what are known as ‘open contacts’ on the
patient electronic record (RiO) are being monitored on a weekly basis. This is where
a patient has had an appointment date that has passed but the episode of care has
not been closed on the record, either by a record of the appointment having taken
place or evidence of a further appointment offered. These will be drawn to the

Chair; Cathy Ellis Chief Executive: Dr Peter Miller

attention of medical staff for a clinical decision. This will strengthen safeguards to
ensure appropriate follow is offered to all patients.

2. Community support did not take place as planned, and the family were not even
made aware that this was awaited and Barry was on the list. It was not clear
what, if any, information Barry had received apart from a very brief letter of
discharge that specifically did not mention the community support.

A referral for community support (community care contact form) was faxed from the
Ward requesting support on 11 November 2014 and was noted in the ward notes but
not in the discharge letter. This should have been recorded as part of the follow up
arrangements in the discharge letter. No information about the delay in assessment
by the Local Authority was received by LPT.

Actions taken/planned:

We have written to all adult mental health clinical staff to inform them that they must
include all referrals to other agencies in the discharge letter and ensure that this is
communicated clearly to patients/carers.

The LPT Discharge Policy is currently under review and the new policy is due to be
approved in February 2016.

The current policy attached as appendix 3 states;

Discharging Mental Health service users with severe mental illness from inpatient
Mental Health Services will be carefully considered in consultation with all
professionals involved and undertaken in consultation with the service user and
(where relevant) their carers or parents. Any such decisions must be clearly
communicated to the GP, the referrer and all parties involved in the service user's
care and the service user themselves.

The new policy will include:

Within 24 hours of the service user's discharge, the doctor must complete the
detailed e-discharge letter which is stored within the electronic records system
within RiO. This must be sent through to the GP via the ICE electronic system (for
surgeries where ICE Is not available, the discharge letter must be sent via either
secure email or fax). The service user / carer must be offered a copy. It should
contain the following information as a minimum:

Initial reason for admission

Investigations carried out and all available results

Clinical summary of treatment

Clear statement of definitive primary diagnosis where confirmed or reason for
not being available

Medication commenced and to be continued, including duration
Medication changed or stopped, and reason

Management Plan/Crisis Plan if problems (i.e. who to contact)
Follow up arrangements and referral to other agencies
Information provided to the service user

Infection Prevention and Control status

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

° Functional ability on discharge

3. The expectation of the Local Authority is that appointments should take place
within 28 days, but the unit is significantly under-resourced and delays are
common and appear to be tolerated, and have been for some time. Earlier, timely
appointments could assist in identifying and intervening with relapsing patients.
This opportunity was lost.

This is a question to be answered by our colleagues from the Local Authority as this
is regarding the Local Authority's Intensive Support Team, not an LPT service. The
LPT Service Manager for Community Mental Health has raised the issue of long
waiting times for assessments by the Local Authority Intensive Support team with
the Head of Service in the Local Authority (City).

4. Communication between the community mental health team and other
stakeholders was poor, with important information that had been identified (that
Barry was depressed and not compliant with his medication) not being shared
with the GP, nor were the GP or psychiatric team aware that Barry was not
receiving any community support.

We agree with the inquest findings that communication between the Community
Mental Health Team (CMHT) and wider stakeholders was poor. We agree that LPT
did fail to communicate the fact that Barry did not attend his outpatient appointment
to his GP and the steps regarding open contacts taken to prevent this happening in
the future have been detailed are outlined above.

We have informed our entire medical and nursing staff, in writing dated 1 December
2015 that they MUST write to GPs informing them about patients who Do Not Attend
at our outpatient clinics as stated in the LPT DNA policy. In addition we will carry out
an audit of the DNA policy to check compliance against the standards in the policy
during quarter 2 of 2016/17. The record keeping audit, being scheduled for January
2016 will also include the recording of compliance with the standards within the
revised discharge policy as described under point 2.

5. Information was not made readily available for either Barry, or the family who
were trying to support him, of who was involved in his care, the extent of their role
and who to contact to discuss this further or in case of any deterioration or
change in presentation. This made the task of the supportive sister considerably
more onerous and difficult and introduced unnecessary further delays in obtaining
support for Barry at a time when his mental health was deterioration and he was
in need of urgent review.

We agree with the inquest findings that information made available for ether Barry or
his family was unsatisfactory and that it is vital that relevant information is available
for patients and their families, that this is provided, documented and made part of
each individual's assessment and care planning.

Actions taken/planned:

LPT is undertaking a ‘Listening into Action’ (LiA) programme around the involvement
of patients and their carers in their care planning. LiA is a structured approach to

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

assist service improvement. The first event in the programme is to be held in
January 2016. Additionally a Trust Carers’ Pack has been developed as part of an
established CQUIN (Commissioning for Quality and Innovation) to provide
information to carers about processes and services. The availability of the same will
be widely publicized by the ward, outpatient staff, and service user and carer
organisations. Team managers will be asked to cascade to all staff once it is
completed and ready for distribution. It is anticipated that this will be completed by
March 2016.

LPT’s CMHTs are currently undergoing service redesign. An important part of this
redesign is to remove internal barriers between our Outpatients Service and the
wider CMHT. Included in this redesign work is a pathfinder project in the North West
Leicestershire CMHT to look at a multi- disciplinary team held caseload model with
the aim to roll this out across all CMHTs by April next year. We anticipate that this
work will help to address the concern about Barry's sister's queries being passed
between different parts of the team including the Consultant Psychiatrist and the
referral management service

In addition staff have been reminded that where family members are present during
an assessment they must be offered the opportunity to give their views, observations
and understanding in relation to the crisis and the support they may be able to
provide. This information will be documented on the assessment form by the
assessing professional and form part of the outcome of assessment. This has been
communicated in writing to our CMHTs.

The CMHTs have also been informed in writing that relevant information must be
made available for patients and their families, where this is provided it must be
documented and made part of each individual's assessment and care planning.

All of the actions outlined in this response will be monitored through the service's
clinical governance arrangements.

We hope this reassures you that we have taken appropriate action in response to the
issues you have raised under Regulation 28 and that we are committed to provide
safe and effective care in order to reduce the risk to our future patients.

Yours sincerely

-

Dr Peter Miller

Chief Executive
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Chair: Cathy Ellis Chief Executive: Dr Peter Miller